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Bella was a role model of strength, endurance and caring for her children and husband. She survived childhood abuse, molestation and a dysfunctional family background. In the end, mental illness did not ravish her life. Rather it was a physical disease.
The book also shows how Dr. Zal changed from an inexperienced, anxious, psychiatric resident and become a wiser, more empathetic therapist. It illustrates how he learned to balance personal angst, the biologic basis of psychiatric illness and the uniqueness of the individual patient into a therapeutic tool. This balancing act, illustrated through Bella's story, is the dance with medusa that has occupied the core of his life in psychiatry.
Dr. Zal is able to weave a 40-year history of psychiatry through this story, including sweeping changes in treatment, mental health laws and the role of the psychiatrist. Using Haverford State Hospital, he tells the story of the transition to community mental health.
Bella's story is about hope, overcoming the stigma of mental illness and the role that determination can play in life success. Her accomplishments reinforce Dr. Zal's firm belief that although psychiatric medications can facilitate improvement in mental disorders, it is people working with people, on a sustained long-term basis, that is equally or even more important, in maintaining recovery and producing emotional growth.
I met Bella for the first time six weeks into my three-year psychiatric fellowship. That day, I came to work at 8:30 AM, walked into the immense formal lobby of Haverford State Hospital's building four and took one of the elevators to the third floor. As the elevator doors opened, I heard a woman yelling, "Stop. Stop," in a high-pitched voice. There, down the hall near the women's ward, I saw an agitated young lady in a yellow and white dress. Her blond hair streamed down her back and flew from side to side as she screamed. She reminded me of Medusa, one of the Gorgon monsters of Greek mythology with snakes for hair. "Can't you see I'm the queen? How can you treat me this way?" She flailed her hands in a threatening manner, thought that she was royalty and yet seemed fearful that someone (Perseus and his forces?) was out to destroy her. The female psychiatric aide that had brought her from the first floor admissions suite, stood by frozen, looking frightened and helpless, not knowing what to do. The ring of metal keys in the aide's hand made a soft musical clanging sound as she trembled.
Scared and hesitant, I walked slowly down the hall concerned that if I looked at her, her deadly powers would turn me instantly into stone, as predicted in the Greek myth. When I reached where she was, I took her hand. She stopped screaming and looked at me with luminous blue eyes that emanated a translucent glow. I walked her gently toward the women's ward, three north, as you would lead someone onto a crowded dance floor, unlocked the door and took her to the nurse's station. She turned back, looked at me and smiled as the aide took her to her room.
The year was 1967. It was August. Actress Vivien Leigh, Scarlet O'Hara in Gone With the Wind, had just died at age 53 of tuberculosis; Stokely Carmichael called for a black revolution in the United States as race riots swept across our land and LBJ announced plans to send 45,000 more troops to Vietnam. My focus was elsewhere. I had just begun my psychiatric fellowship. Prior to this, I had completed a one-year rotating internship in Columbus, Ohio. This training had involved the medical management of patients under the supervision of an attending physician on various specialty services. I had no formal psychiatric experience except for a few medical school courses, a psychiatric rotation in my fourth year of medical school and a summer of employment in the Industrial Therapy Department at a state psychiatric hospital.
I felt overwhelmed during my first few months at Haverford State Hospital. My job involved a lot of responsibility. I asked many questions and learned by doing. As a ward or staff physician, I was put in charge of the psychiatric and medical management of 30-50 inpatients. This included the prescription of medication, individual and group therapy, as well as supervision of their milieu and activities. I also administered electroconvulsive therapy, saw 25-30 outpatients monthly and often did counseling of family members. Clerical work included dictation of progress notes, completion of insurance forms and letters to other agencies. I also worked in the admission suite on a rotating basis and presented periodic special case conference dissertations for staff education.
Bella was not my first patient. The hospital had already assigned fourteen other inpatients to my service during the prior month. I got my first patient after two weeks of orientation. Excited as could be and filled with fantasies of facilitating a magical cure, I rushed to the 3-N female unit to meet her. I opened the large metal door to enter the locked unit. Still a novice in this world, I had a strange feeling of happiness that I had the keys, which clearly defined me as staff and not a patient. I ran onto the unit to find Ms. Benita Benson lying on her back immobile and mute on the hallway floor. "I'm Dr. Zal," I said. She did not respond. She was catatonic. I lifted her arms and pulled her toward me. They remained where I left them. I attempted to move her. Her posture remained rigid. I watched in amazement as two male psychiatric aides carried her to her room. I stood there feeling helpless and inadequate. I almost wished that they had assigned me a patient with wild and unpredictable catatonic excitement rather than this stuporous, inactive and unresponsive catatonic schizophrenic woman on the floor.
The morning of my first interview with Bella, I unlocked the heavy door of 3-N women's unit eager but anxious to see the new patient who had been so regressed and disturbed two days earlier. Immediately the noise hit me. The female unit had a tone of uproar, commotion and confusion like the tower of Babel. I walked down the long, monotonous hallway to the small physician's office on the left. I passed the stark conference room, with its long wooden table and chairs, where we held our weekly new case conference. In front of the physician's office was the glass enclosed and locked nursing station, which isolated two psychiatric aides and a nurse, from the din of the large day room, as they busily took off orders and wrote notes in patient's charts. Small single and double patient rooms in front and to the right outlined the dayroom. I unlocked the doctor's office and entered quickly, happy to escape the racket.
I sat in the drab, 8' x 10', physician's office for a while and tried to relax. The room had a sterile feel, with its green walls, gray metal desk, chair and bookcase and single window. A desk lamp, phone and a panic button were the only accessories. My security blanket was the nineteenth printing of the Diagnostic and Statistical Manual of Mental Disorders, first edition, published by the American Psychiatric Association in August of 1966. The room lacked any element of warmth. It did not even have a picture or a wall calendar to soften its cold look. I took a deep breath, opened the metal patient chart with its multicolored paper dividers and reviewed her records including her past psychiatric history.
Bella was Haverford State hospital patient # 4032. She was 20 years old. The thought came to me that, at age 26, I was not much older. She had two prior psychiatric hospitalizations. She had been hospitalized for the first time in May of 1966 at age 19 at Dufur Hospital, Ambler, Pa. After 10 days, she had been transferred to the psychiatric unit at Misericordia General Hospital, Philadelphia, Pa. There, she received 12 electro shock treatments. She remained there until July of 1966 when she was discharged home. She apparently stayed well until a short time before her admission to Haverford State Hospital on August 16, 1967.
After reviewing the chart, I called the nursing station. Lorraine, an aide, brought Bella into the room to see me. I stood up and walked toward them extending my hand. Lorraine said, "Bella this is Dr. Zal. He would like to ask you some questions." Her hair had been brushed straight. She was neatly dressed in a hospital gown and seemed much younger than her stated age. Gone was the ferocity that I had seen previously. Now medicated, she was passive, withdrawn and walked slowly, scanning the room suspiciously. I said hello, shook her hand and introduced myself as warmly as I could. "I would like to get to know you and see how I can be of help. Will you take a seat here?" In a quiet voice, she answered, "I'm Bella," as she took a seat in a chair on the side of the desk. "I'm glad to meet you Bella," I said as I returned to my seat. She sat up straight with her back tensing firmly against the back of the metal chair and her hands folded tightly in her lap. She looked prim and proper. Two mental images came to my mind. On the one hand, she could have been a habited nun. On the other hand, I could picture her as an efficient secretary coming to work in a shirtwaist dress popular at the time with matching gloves, shoes and handbag. She was calmer but guarded, internally focused and still clearly psychotic. My job that day was to complete a standard mental status evaluation. I started by saying, "Bella, since it is our first meeting I will have to ask you many questions so I can get to know you and try to help. There are no trick questions. Just answer the best that you can."
I asked, "Bella can you tell me what date it is and where you are?" She knew it was Thursday, August 18, 1967 and that she was at Haverford State Hospital. "I thought that you would know that one," I quipped in an effort to relax her.
"Why are you here?"
"My mother was upset with me. I wouldn't do what she wanted."
I made a mental note to ask her about her relationship with her mother in future sessions.
"Bella, when you read a newspaper or watch television, can you focus and pay attention?"
"I can sometimes."
"How is your memory? Are you forgetful?"
"My memory is fine."
She was able to subtract serial sevens correctly (100-7 = 93; 93-7 = 86, etc.), but it took her a long time to complete the task. She seemed perplexed and distracted at times but I could see that she was trying to cooperate.
I asked her to read a selected paragraph from the hospital manual about the administration. She interpreted it in terms of her own delusional thoughts. "It means that I know that I have followers."
Bella's responses seemed flat, depressed and indifferent. When I asked her, "Do you feel depressed?" She answered, "a little." I asked her if she wished that she was dead or if she wanted to harm herself. She denied any thoughts of suicide and stated, "My conscience would tell me no. It would tell me to keep trying." I was glad to hear this and breathed a sign of relief.
Bella spoke in a slow manner and seemed anxious. She showed undirected restlessness during most of the interview. She impulsively picked up papers from the desk, walked around the room and even wrote her name in one of the books on my desk. At one point, when she seemed to have withdrawn into herself, I asked her "Bella, what are you thinking about?"
"I feel very confused," she said. "People are trying to play tricks on me; the room is bugged. I can't talk freely inside a building."
Twice during the interview, the phone rang. Bella, who has been previously calm and withdrawn, became agitated and irritable. "I wish someone would answer that silly phone." The second time, I asked her, "Why did you get so upset when the phone rang?" She stated, "I feel this way because no one ever calls me."
Bella went on to tell me a long story, which jumped from one subject to another in a loose and round about manner. There were religious themes. Bella explained her current behavior as follows: "When I was little, I loved to daydream. The nuns at school told me stories about religious figures and their kind deeds. I would go home and hear the fighting and screaming and wanted things for myself and couldn't get them." She stated that she felt that she was different from other girls that had normal families. These answers gave me ideas for questions that I wanted to ask Bella in upcoming sessions.
When I asked her what she thought she might like to do in the future, she answered grandiosely, "I would like to help the country and President Johnson." She also stated, "I only want to get married and live a normal life. I need someone to take care of me."
She did seem vulnerable and helpless during this interview. As I got to know Bella better, I realized that when she was well, she radiated an innocence that was deceptive. In fact, she knew exactly what she wanted and how she wanted things to be done. This facade melted away when she was about to became psychotic. At these times, she faded like one of the tapered golden beeswax candles that she loved to make as an adult. What remained was a fragile, vulnerable, childlike inner core of molten wax that said, "Love me; protect me; save me."
"Bella have you ever heard a voice talking to you and you turned around and there really was no one there?" "No, she said, but sometimes, I heard crickets." "Have you ever seen visions?" I asked. She answered, "One time last year, while I was in the mountains, I saw something terrible, someone that was red, something that I did not understand that made me tremble"
"Bella, who are the last three presidents of the United Sates," I asked. She answered, "President Nixon, Kennedy and Johnson. I Liked Kennedy."
I asked, "What would it mean if someone said, 'People who live in glass houses shouldn't throw stones?" She answered, "People that think that they are so great can see bad within everyone else, but not within themselves. They are really the stones." In response to the proverb, 'Don't cry over spilt milk', she said, "Things I have done in the past should not be cried over."
Bella had some insight in that she realized that she was ill. She stated, "I hope that you can help me with my problems."
"We are finished for today. It was nice to meet you. Thank you for sharing your thoughts with me. I will see you again and I will try to help you with your problems. I'll take you back to the ward now." With that, I led her back into the day room. She walked slowly to the old spinet piano against the far wall and began to play Beethoven's Fur Elise, one of the few songs that I had learned by heart as a young piano student.
Latter that day, I wrote in her chart:
Diagnostic Impression: Schizophrenia Reaction, Paranoid Type 000-x24
Six weeks earlier, I had crossed over Montgomery and Lancaster Avenues on the Philadelphia Main Line. I passed the back of the prestigious Haverford School and then the grounds of Haverford College. Soon I saw beautiful homes that lined both sides of College Avenue, with their manicured lawns, dense shrubbery, and circular driveways. I had not been here for two years and had forgotten the beauty of this road. However, I knew that in just a few minutes, I would come a long way from these magnificent palatial homes to a home for troubled souls. When College Avenue became a dead end, I made a right turn unto Darby Road.
There, I saw a five-foot high semicircular gray stone wall. I was surprised that there was no sign marking the transition from serene opulence to the psychiatric treatment facility that was Haverford State Hospital, at 3500 Darby Road, in Haverford, Pennsylvania. There was no gate or fence. I made a left turn. On one side of the narrow road, I saw tall trees bordering a vacant lot. On the other side, flowering trees brought my eyes to a five story red brick building with two wings facing front. I saw a person looking out of one of the large, light blue-topped windows. This was building four, the admissions unit. My heart started beating faster with nervousness and excitement. The last time that I was here, I had been a student. This time, I was a physician. I parked my steel blue triumph GT-6 in front of the building. I slid my thin six-foot frame out of the low-slung car. I became annoyed when I realized engine oil had dripped on my shoes. This was my first day at work and I wanted to present my self well. I smoothed down my kaki suit jacket, straightened my tan knit tie against my white starched shirt, and walked across the road. I entered building three, the administration building. I filled out some employment papers and received my keys. I also learned that as an Osteopathic Fellow in Psychiatry, through the Philadelphia Mental Health Clinic, under the auspices of the National Institute of Mental Health, the state would hire me as a Ward Physician with a class title of Staff Physician I. This position paid a salary of $14,612.00 a year. This was considerably more than I had ever made before. I had received $3,000 during my internship. This pay scale was more than double the salary that I would earn in the second and third year of my fellowship training at the outpatient clinic.
Excerpted from Dancing with Medusa A Life in Psychiatry by H Michael Zal Copyright © 2010 by H Michael Zal. Excerpted by permission.
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Posted July 22, 2010
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